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  1. 1. AUTISMASHRAF TANTAWYProfessor of Psychiatry Suez Canal University Ismailia, Egypt.
  2. 2. A Complex Developmental Disability.The Most severe neuropsychiatric condition inchildhood.Autism first described by Kanner (1943).Typically appears during the first threeyears of life.Triad of impairments: 1- Socialization. 2- Communication. 3- Imagination.
  3. 3. Autism Spectrum Disorders (ASD) Pervasive Developmental Disorders Childhood Autistic Rett’s Disintegrative Disorder Disorder Disorder Asperger’s PDD- Disorder Not Otherwise Specified (Atypical Autism)
  4. 4. Autistic DisorderICD-10 & DSM-IV-TR1) Social Interactions Impairment: Nonverbal Behaviors: Gestures. Peer Relationships. Spontaneous Sharing. Reciprocity. Joint Attention. Eye Contact: Poor or Avoidant. Making the Connection.
  5. 5. Autistic Disorder ICD-10 & DSM-IV-TR2) Communication Impairment: Spoken Language. Abnormal Prosody of Speech. Idiosyncratic Words. Initiate or Sustain Conversation. Stereotyped Language. Making Social Play.
  6. 6. Autistic Disorder ICD-10 & DSM-IV-TR3) Restricted, Repetitive & StereotypedBehavior, Interests or Activities: Intense Preoccupations. Inflexible Routines or Rituals. Stereotyped Motor Mannerisms. Preoccupation with Parts of Objects. Getting Stuck.
  7. 7. Red Flags… NICHD suggests doctors consider an evaluation if: The child does not respond to his/ her name. The child cannot explain what he/ she wants. Language skills or speech are delayed. The child doesn’t follow directions. At times, the child seems to be deaf. The child seems to hear sometimes but not others. The child seems to be in his/ her “own world.” The child is not interested in other children. The child walks on his/ her toes. The child shows unusual attachments to toys or objects. The child spends a lot of time lining things up or putting things in a certain order.
  8. 8. Red Flags continued… The child doesn’t point or wave bye-bye. The child used to say a few words but now he/ she doesn’t. The child throws intense or violent tantrums. The child has odd movement patterns. The child is hyperactive, uncooperative or oppositional. The child doesn’t know how to play with toys. The child doesn’t smile when smiled at. The child has poor eye contact. The child gets “stuck” on things over & over & can’t move on to other things. The child seems to prefer to play alone. The child gets things for him/ herself only. The child is very independent for his/ her age.
  9. 9. Prevalence of Autism2-6 cases per 1,000.Boy : Girl = 4:1.Usually identified before 36 months.No racial or socioeconomic differences.
  10. 10. Important Roles of Primary Care Physicians/Medical HomeEarly recognition:– Knowledge of signs & symptoms.– Developmental surveillance & screening.Guiding families to diagnostic resources &intervention services.Conducting a medical evaluation.Providing ongoing health care.Supporting & educating families.
  11. 11. Screening in Primary CareSurveillance for Social &Communication skills.Screen at 18 & 24 months withspecific screening test.Reassess at well child visits(Diagnosis for children with highfunctioning ASD).
  12. 12. ASD Screening in Primary CareChildren at Higher Risk:– Siblings of children with ASD: 10 x increased risk.– Premature Infants.– Comorbid Genetic Syndromes: e.g. Fragile X syndrome, Tuberous Sclerosis.– Prenatal Exposures e.g. Valporic acid.Regression in Milestones: 25-30%.– 15-24 months of age.– Change in language, social awareness or behavior.
  13. 13. Diagnostic EvaluationApplication ICD 10 or DSM IV TR Criteria:– History.– Observational Measure.Medical & Physical History:– Behavioral History.– Family History: Genetic risk factors.Assessment includes: IQ, Speech, Language,Adaption, Motor, Social, Emotional &Hearing.Assessment of Parents: Understanding, CopingSkills & Resources.
  14. 14. Diagnosing Tests for AutismSeveral tests have been developed that arenow used in diagnosing autism:– CARS: Childhood Autism Rating Scale.– CHAT: Checklist for Autism in Toddlers.– ASQ: The Autism Screening Questionnaire.– STA: Screening Test for Autism in 2 Yrs.
  15. 15. Medical Work UpGenetic Testing Karyotype: 5%. Microarray: 6-27%. Fragile X: 1-2%. MeCP2 FISH Chr 15: 1%.Metabolic Testing Amino Acids-<1% Organic Acids<1%Neuroimaging MRI, any lesion-up to 48%EEG Any abnormality-16-68% Seizures- 25% lifetimeOther Low Lead.
  16. 16. ManagementGoals:– Minimize core & associated deficits.– Maximize functional independence & QOL.– Alleviate family stress.Educational Intervention.Developmental Therapies:– Communication.– Sensory, Fine Motor & Gross Motor.Behaviorally Based Treatments:– Core & associated symptoms.– Social Skills.Medical Treatments.
  17. 17. Medical ManagementTreatment of Coexisting Problems:Epilepsy, Behavior & Sleep disorders.Medication Management For:Inattention, Impulsivity, Irritability &Aggression.
  18. 18. Medical ManagementComorbid Symptoms or ConditionsHigh rates of co-morbidity Tic Disorders (10%). Seizures (25%). ADHD (30-75%). Affective Disorders (25-40%). – e.g., Depression or Anxiety . – Higher in Asperger’s. GI Problems (10-60%). Sleep Disturbance (50-75%). Challenging Behaviors (10-35%).
  19. 19. Nutrition In AutismFood Sensitivities: Psychoactive peptides fromimproperly digested casein (milk) or gluten-based (wheat) foods affect brain function insome autistics.Gluten-Free Diet Suggestions:– Instead of wheat flour, use potato, rice, soy or bean flour.– Red meat, fish, rice, fruits, beans, nuts, seeds & vegetables do not contain gluten.– Avoid all foods that contain wheat, oats, pasta, cereal & many processed foods.
  20. 20. Nutrition In AutismCasein-Free Diet Suggestions:– Instead of cows milk, use rice or potato milk.– Eggs do not contain casein.– Avoid foods that contain Casein: milk, yogurt, cheese, ice cream & pudding.Vitamin & Mineral Supplements:- If a diet is high in overly processed foods, a person may be deficient in vitamins C, E, B6 & minerals such as magnesium, molybdenum, chromium & selenium.
  21. 21. ASD OutcomeOutcomes are Variable: Ongoing problems with independent living, employment, social relationships & mental health.Predictors of Better Outcome:– Earlier Age of Diagnosis & Treatment.– No Cognitive Impairment.– Early Language & Nonverbal Skills.– Social Skills.
  22. 22. ConclusionAUTISM: A Complex Developmental Disability.Severity: The Most severe neuropsychiatriccondition in childhood.Typically appears during the first three years of life.Triad of impairments: Socialization, Communication& Imagination.Management Goals: Minimize core & associateddeficits, Maximize functional independence & QOL& Alleviate family stress.